Action Points

Note that these guidelines were presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Proposed guidelines for lung cancer screening from the American College of Chest Physicians are an attempt to balance the balance of benefit and harms associated with low-dose computed tomography (LDCT).

The key recommendation outlines who should be offered yearly LDCT lung cancer screening, specifically asymptomatic adults, ages 55 to 77, with a smoking history of at least 30 pack-years or more who either continue to smoke or have quit within the past 15 years.

TORONTO -- Proposed guidelines for lung cancer screening are an attempt to balance the balance of benefit and harms associated with low-dose computed tomography (LDCT), experts said here.

The guidelines are "largely based" on the results of the landmark National Lung Screening Trial (NLST), but also include data from similar trials elsewhere, as well as expert opinion in areas where evidence is lacking or limited, according to Peter Mazzone, MD, of the Cleveland Clinic in Ohio, the chair of the guidelines panel.

The goal was to help physicians and policy-makers understand how to set up and run screening programs in a "high-quality" manner, Mazzone told MedPage Today.

The guidelines, presented at CHEST, the annual meeting of the American College of Chest Physicians, and online at the college's website, are still under peer review, Mazzone noted, and might still change during that process.

The key recommendation outlines who should be offered yearly LDCT lung cancer screening, specifically asymptomatic adults, ages 55 to 77, with a smoking history of at least 30 pack-years or more who either continue to smoke or have quit within the past 15 years.

That slightly extends the college's earlier guidelines, which referred to patients ages 55 to 74.

That new age bracket is in line with what the Centers for Medicare and Medicaid Services will pay for, but is slightly more restrictive than the 2103 guidelines of the U.S. Preventive Services Task Force (USPSTF), which suggest ages 55 to 80.

It's also pretty much in line with the patient population in the NSLT, which enrolled more than 53,000 people who were or had been heavy smokers, but had no symptoms suggestive of lung cancer and were otherwise healthy. At the end of that study, the oldest participants were 77.

They were regarded as being at high risk mainly on the basis of age and smoking history, but were also seen as being healthy enough to undergo invasive testing if the screening found something or treatment if the detected lesion turned out to be malignant.

Many people won't fit the screening group, Mazzone said, because their age, smoking history, or health does not meet requirements. But clinical risk calculation algorithms that look at other factors -- a family history of cancer, for instance -- might still show they are at high risk of lung cancer.

For those people, the guidelines suggest LDCT screening should not be offered on a routine basis, although for individual patients it might be warranted, especially if they have little comorbidity.

"Right now, there is not enough evidence to screen people outside of what we originally recommended," said guidelines panel member Gerard Silvestri, MD, of the Medical University of South Carolina in Charleston.

But some patients will still be at high risk and could be screened, he noted. The guidelines suggest that one example of high risk would be a threshold of 1.51% over 6 years on the PLCOm2012 calculator.

The guidelines also suggest that doctors should not screen::

People outside the age and smoking history brackets who don't have a high risk on a clinical risk prediction calculator

People with comorbidities that make it difficult for them to tolerate either evaluation of any findings or treatment of cancer, or that substantially limit their life expectancy

The rest of the recommendation guidelines look at ways to help doctors and policy-makers establish screening programs in ways that "make sure they're optimizing the balance of benefits and harms," Mazzone said,

For instance, the panel urges that screening programs find ways to detect patients who have symptoms that suggest the presence of lung cancer, so they get diagnostic testing instead of screening.

People running such programs should also set up procedures to deal with incidental findings outside of lung cancer, they urge.

Panel member Renda Soylemez Wiener, MD, of Boston University Medical Center, outlined a range of possible harms, including overdiagnosis, invasive biopsies to test for cancer, and complications from those procedures.

And she noted there is evidence some of those -- for instance, detection of non-cancerous lesions, or false alarms -- might be higher in the real world than they are in clinical trials.

To come up with the recommendations, the panel looked at more than 3,000 publications, which were eventually winnowed down to 57 papers, including 10 randomized controlled trials and 12 cohort studies.

Mazzone and co-authors disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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